BASIC (03-12)

DI 25505.030 Evaluation of the Duration Requirement for Disability

Citations:

Regulations — 20 CFR 404.1522, 404.1523, 404.1598, 416.922, 416.923, 416.998

Social Security Rulings — SSR 82-52

Consider duration in the context of the sequential evaluation process. The duration requirement is not an issue in the disability determination unless the claimant’s impairment(s) is severe and prevents substantial gainful activity (SGA), or for children, the child’s impairment(s) is severe and results in marked and severe functional limitations.

A. Claims involving multiple impairments

If a claimant has multiple impairments, consider the combined effect of all impairments, unless one impairment, when considered separately, is of sufficient severity and duration for an allowance.

1. Unrelated severe impairments

If a claimant has a severe impairment(s) and then develops another unrelated severe impairment(s), but neither one is expected to last for a continuous period of 12 months, you cannot combine the expected duration of the unrelated impairments to meet the duration requirement.

2. Concurrent impairments

If a claimant has two or more concurrent impairments and these impairments, when considered in combination, are so severe as to prevent SGA, decide whether the combined effect of the concurrent impairments is expected to prevent SGA for 12 continuous months. If one or more of the impairments improves, or is expected to improve within 12 months, and the combined effect of the remaining impairment(s) is no longer so severe as to prevent SGA, the 12-month duration requirement is not met.

3. CDRs with a new impairment

In continuing disability review (CDR) cases, if a claimant has a new disabling impairment(s) that begins in or before the month in which the last disabling impairment(s) is no longer disabling, the period of disability continues. The new impairment(s) must be so severe as to prevent SGA, but it does not need to be expected to result in death or last for a continuous period of 12 months. For children, the new impairment(s) must be severe enough to result in marked and severe functional limitations.

Conversely, if a claimant has a new disabling impairment(s) that begins after the cessation month, you must determine if the new disabling impairment can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. To establish a new period of disability, the new impairment(s) would need to meet the duration requirement. For more information on the CDR evaluation process regarding new impairments and subsequent disability, see DI 28005.210.

B. When and how to determine “expected duration”

When adjudicating a claim within 12 months of the date the claimant first met the medical criteria for disability, determine the “expected duration” of the claimant’s impairment(s), if necessary, by projecting whether the impairment(s) is expected to result in death or continue to be severe and prevent performance of SGA for a continuous period of not less than 12 months. In child cases, project whether the impairment(s) will continue to be so severe that it causes marked and severe functional limitations.

Consider the nature and course of the impairment(s), as well as the claimant’s treatment history, by evaluating the following evidence:

  • symptoms, signs, and laboratory findings;

  • frequency, dosage, and effects of medication;

  • surgery, radiation, or chemotherapy; and

  • treatment response, such as improvement or worsening in symptoms, signs, and laboratory findings.

Longitudinal evidence is extremely important and necessary when evaluating the severity of a mental impairment(s). A claimant’s level of functioning can vary considerably over time. It is vital to obtain evidence from relevant sources over a sufficiently long period prior to the date of adjudication to establish severity and probable duration of the impairment(s).

C. Severity and the duration requirement

In most cases in which evidence supports a finding of disability, it will be clear whether the impairment(s) is expected to result in death or has lasted or is expected to last for a continuous period of not less than 12 months from the onset of disability. If you adjudicate the case before a disabling impairment(s) has lasted 12 months, it is necessary to project severity. You will need to explain why you believe the impairment(s) is expected to result in death, or has lasted or can be expected to last for a continuous period of not less than 12 months. If you are adjudicating a case within 12 months of onset and the impairment has never been disabling, it is not necessary to project severity.

1. Projecting severity

The nature of the impairment, the medical history, and the prescribed treatment are necessary considerations before you can determine if the impairment(s) is expected to result in death or will continue to prevent the claimant from engaging in SGA for the additional months needed to make up the required 12 months duration. If you expect a claimant’s severe impairment(s) to improve, it may be necessary to project severity at 12 months from onset.

Example of projecting severity where improvement is expected:

A claimant fractured his femur and he is only able to walk by using a walker. At 3 months post fracture, current imaging showed there was not a solid union and he still could not ambulate effectively.

You could consider listing 1.06B Fracture of the femur, tibia, pelvis, or one or more of the tarsal bones. However, by assessing the nature of the impairment and evaluating the treatment he is receiving, you can project severity and determine that he will likely recover and return to effective ambulation within 12 months of onset. A durational denial is appropriate because the impairment is not expected to last a continuous period of not less than12 months.

NOTE: Projecting severity may involve projecting residual functional capacity (RFC) as explained in DI 25505.030E.1. in this section.

2. Severe impairment(s) responsive to treatment

A claimant may have a severe impairment(s) that has responded to treatment and has restored his or her ability to work, or for a child, his or her ability to function. If the claimant has met the duration requirement, he or she may be entitled to a closed period of disability. For more information on closed periods, see DI 25510.000.

NOTE: To support a closed period of disability, the adjudicator must establish that medical improvement has occurred. For more information on the medical improvement standard, see DI 28010.000.

3. Child’s severe impairment(s) does not meet duration requirement

If a child’s medically determinable impairment(s) is or was of listing-level severity, but is not expected to result in death or be of listing-level severity for a continuous period of not less than 12 months, the child’s impairment(s) does not meet duration requirement and you must deny the claim. The child’s Personalized Disability Notice (PDN) should explain that, within 12 months of onset, the child’s impairment(s) no longer results or is no longer expected to result in marked and severe limitations; therefore, the claim is denied.

4. Non-severe durational denial

If there is or will be no significant limitation of the claimant’s ability to perform basic work-related activities due to a physical or mental impairment (i.e., non-severe), the duration requirement is not met and you must deny the claim.

In child cases, if a physical or mental impairment causes or is expected to cause no more than minimal functional limitations by the end of 12 months, the duration requirement is not met and you must deny claim.

The PDN for adults should explain that, within 12 months of onset, there was or is expected to be sufficient restoration of function so that there is or will be no significant limitation of the ability to perform basic work-related functions.

The PDN for children should explain that, within 12 months of onset, there was not or is not expected to be any impairment(s) of such severity that would result in marked and severe functional limitations.

D. Disabling level of severity

The Listing of Impairments (the listings) describe impairments we consider severe enough to prevent a claimant from doing any gainful activity. For children under title XVI, the impairment(s) must be severe enough to cause marked and severe functional limitations. 20 CFR 404.1525(c)(3) states, “We will find that your impairment(s) meets the requirements of a listing when it satisfies all of the criteria of that listing, including any relevant criteria in the introduction, and meets the duration requirement.”

IMPORTANT: Medical deferment may be necessary to allow enough time to secure the medical evidence needed to determine duration. For information on medical deferment, see DI 25505.035.

E. Impairment(s) does not meet or medically equal a listing

1. Projecting RFC

It may be necessary to project RFC to show the claimant’s predicted functional capacity at 12 months from the onset of disability if:

  • the impairment does not meet or equal a listing, but continues to be severe 12 months from onset;

  • the impairment(s) is currently at listing level but is expected to improve, and there are significant limitations to performing basic work activities;

  • the claimant has a disabling impairment currently, adjudication is within 12 months of onset, and the impairment is not expected to result in death or be disabling at the end of the 12 months; or

  • the claimant has a disabling impairment currently, adjudication is within 12 months of onset, and the impairment is expected to result in death or be disabling at the end of 12 months.

In certain instances, more than one RFC assessment may be necessary to address onset and duration, although this would be unusual. For more information on multiple RFC assessments, see DI 24510.020C.3.

The effects of any type of limitation(s) when projecting RFC vary greatly, depending upon the degree of the claimant’s limitations, and you must determine them based upon the facts of each individual case. Projecting RFC is a matter of adjudicative judgment.

Example of projection of RFC:

The claimant had a skiing accident and sustained multiple broken bones, a collapsed lung, and abrasions on 01/25/2011. You are assessing the claim on 04/03/2011, after receiving all of the requested medical evidence.

The claimant’s condition is not of listing level; however, he is still very slow in recuperating. You anticipate that the claimant’s current condition is much worse than it will be on 01/24/2012.

Since his condition prevents SGA, you should project his RFC to reflect his predicted functional capacity on 01/24/2012; i.e., 12 months from the date the claimant first met the medical criteria for disability.

When projecting RFC, on page 1 of the RFC Assessment form (SSA-4734-BK or SSA-4734-F4-SUP), select the block that says “Date 12 Months After Onset” and enter the applicable date. You must explain in your narrative that the RFC reflects the claimant’s functioning 12 months from the date the claimant first met the medical criteria for disability. For more information on how to complete the physical RFC assessment form, see DI 24510.050.

NOTE: Do not project the RFC if a claimant’s impairment(s), though severe, does not currently prevent the claimant from engaging in SGA. In this case, a denial based on performance of SGA or an assessment of function and ability to do past or other work is appropriate. For an explanation of policy for projecting the RFC, see DI 24510.020A.

2. RFC and the duration requirement

If you expect a claimant to be able to engage in SGA before the end of 12 months despite significant remaining limitations, then the claimant has not met the duration requirement and you will deny the claim. The PDN must explain that within 12 months of onset, there was, or is expected to be, sufficient restoration of function that, in spite of significant remaining limitations, the claimant should be able to engage in SGA considering the vocational factors of age, education, and previous work experience.

If there is not sufficient evidence in file to determine response to treatment in order to project severity or a claimant’s RFC, obtain supplemental evidence. Consider whether deferred development could potentially provide the evidence necessary to project RFC. For guidance on medical deferment, see DI 25505.035.

IMPORTANT: It is extremely important to thoroughly evaluate, document, and rationalize the claimant’s RFC, work history, and vocational potential when considering a durational denial. The determination may require consulting with all members of the adjudicative team. For further discussion on adjudicative roles and responsibilities of disability examiners (DE), medical consultants (MC), and psychological consultants (PC), see DI 24501.001.

NOTE: When considering vocational issues for claimants with a disabling impairment(s) requiring a projected RFC, the relevant period for past work is 15 years before the end of the projected 12-month period. For a chart on relevant work periods, see DI 25001.001B. If it is necessary to proceed to Step 5, use the age the claimant will be at the end of the 12-month period.

F. Performance of work activity before meeting the duration requirement

If a claimant with a severe impairment(s) performs work prior to meeting the 12-month duration requirement, then the claimant may:

  • have medically recovered;

  • be working despite meeting the medical requirements for Social Security Disability; or

  • have work that may be an unsuccessful work attempt (UWA), subsidized, or involve impairment-related work expenses (IRWE).

For more information on these topics, see DI 24005.001, DI 24001.025, and DI 24001.035 respectively.

The appropriate action, as explained below in this section, depends on factors such as the type of claim (title II or title XVI) or the timing of the return to SGA.

The answers to the following questions will help determine which action(s) is necessary:

  • Is the work SGA?

  • When did the work begin?

  • Is the work continuing?

  • If not, when did the work end?

If you have not adjudicated the claim and the Disability Determination Services (DDS) receives information indicating there is work activity that could be SGA, cease further development and contact the field office (FO) for a resolution of the work issue.

If you have adjudicated and allowed the claim, then disability may continue, subject to a trial work period (TWP), or you may have to reopen and revise the prior favorable determination to a denial or establish a later onset date.

See also:

  • DI 10501.025 Field Office (FO) and Disability Determination Services (DDS) Responsibilities and Procedures for Work Issue Cases

  • DI 25501.390 Considering Substantial Gainful Activity (SGA) and Past Work when Establishing the Established Onset Date (EOD)


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DI 25505.030 - Evaluation of the Duration Requirement for Disability - 05/06/2015
Batch run: 05/06/2015
Rev:05/06/2015